OTA Documentation 2

Question 1

Which documentation format uses a structured note divided into Subjective, Objective, Assessment, and Plan sections?

Accepted Answer

SOAP note

Answer

SOAP notes organize documentation into Subjective (patient report), Objective (measurable findings), Assessment (clinical interpretation), and Plan (treatment direction).

Question 2

An OTA documents that a patient 'ambulated 50 feet with minimal assist.' This is an example of what type of documentation?

Accepted Answer

Objective data

Answer

Measurable, observable performance data such as distance walked and level of assist is objective documentation.

Question 3

Which abbreviation is commonly used in OT documentation to indicate a patient requires no physical assistance?

Accepted Answer

Ind

Answer

'Ind' or 'I' stands for Independent, meaning the patient completes the task safely without any assistance.

Question 4

When documenting a home program provided to a patient, the OTA should record:

Accepted Answer

The program instructions and patient/caregiver comprehension

Answer

Documentation of a home program must include what was taught and evidence that the patient or caregiver demonstrated understanding.

Question 5

A patient states she is 'too tired to do therapy today.' How should the OTA document this?

Accepted Answer

As subjective data, quoting the patient directly

Answer

Patient-reported feelings and statements are subjective data and should be documented using the patient's own words in quotation marks.

Occupational Therapy Assistant Test Practice Test

Occupational Therapy Assistant Test Practice Test

OTA Documentation 2